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. 2017 Oct;10(10):e003863.
doi: 10.1161/CIRCHEARTFAILURE.117.003863.

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support

Michael S Kiernan  1 , E Wilson Grandin  2 , Marshall Brinkley Jr  2 , Navin K Kapur  2 , Duc Thinh Pham  2 , Robin Ruthazer  2 , J Eduardo Rame  2 , Pavan Atluri  2 , Edo Y Birati  2 , Guilherme H Oliveira  2 , Francis D Pagani  2 , James K Kirklin  2 , David Naftel  2 , Robert L Kormos  2 , Jeffrey J Teuteberg  2 , David DeNofrio  2
Affiliations

Early Right Ventricular Assist Device Use in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation: Incidence and Risk Factors From the Interagency Registry for Mechanically Assisted Circulatory Support

Michael S Kiernan et al. Circ Heart Fail. 2017 Oct.

Abstract

Background: To investigate preimplant risk factors associated with early right ventricular assist device (RVAD) use in patients undergoing continuous-flow left ventricular assist device (LVAD) surgery.

Methods and results: Patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent primary continuous-flow-LVAD surgery were examined for concurrent or subsequent RVAD implantation within 14 days of LVAD. Risk factors for RVAD implantation and the combined end point of RVAD or death within 14 days of LVAD were assessed with stepwise logistic regression. We compared survival between patients with and without RVAD using Kaplan-Meier method and Cox proportional hazards modeling. Of 9976 patients undergoing continuous-flow-LVAD implantation, 386 patients (3.9%) required an RVAD within 14 days of LVAD surgery. Preimplant characteristics associated with RVAD use included interagency registry for mechanically assisted circulatory support patient profiles 1 and 2, the need for preoperative extracorporeal membrane oxygenation or renal replacement therapy, severe preimplant tricuspid regurgitation, history of cardiac surgery, and concomitant procedures other than tricuspid valve repair at the time of LVAD. Hemodynamic determinants included elevated right atrial pressure, reduced pulmonary artery pulse pressure, and reduced stroke volume. The final model demonstrated good performance for both RVAD implant (area under the curve, 0.78) and the combined end point of RVAD or death within 14 days (area under the curve, 0.73). Compared with patients receiving an isolated LVAD, patients requiring RVAD had decreased 1- and 6-month survival: 78.1% versus 95.8% and 63.6% versus 87.9%, respectively (P<0.0001 for both).

Conclusions: The need for RVAD implantation after LVAD is associated with indices of global illness severity, markers of end-organ dysfunction, and profiles of hemodynamic instability.

Keywords: atrial pressure; blood pressure; heart; humans; risk factors.

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Figures

Figure 1
Figure 1
Consort diagram of the study population from the INTERMACS registry. Patients requiring a right ventricular assist device (RVAD) use within 14 days of continuous flow left ventricular assist device implantation were compared to those who did not.
Figure 2
Figure 2
Receiver operating characteristic curve (ROC) of the logistic regression model for the end-point of right ventricular assist device (RVAD) use within 14 days of continuous flow left ventricular assist device implantation. Sensitivity (Sens), specificity (Spec), positive predictive value (ppv), and negative predictive value (npv) are provided at four points along the ROC curve.
Figure 3
Figure 3
Kaplan Meier survival curves for patients with (hashed line) and without (solid line) right ventricular assist device (RVAD) use within 14 days of continuous flow left ventricular assist device implantation. Table inserts provide the estimated survival and 95% confidence limits for patients with and without RVAD use at selected time points.
See this image and copyright information in PMC

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